Disabilty_Hall MF-R,•. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
`a 1\. DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R13/1-20) l 6 SO �{
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" , Prescribed by the Department of Local Government Finance `�' Z J � _i
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Date Form must be completed and signed by December 31 and filed or postmarked by the following January 5 of the calendar year in which the
property taxes are first due and payable
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)' f
f�i M\,er ly NCB <<
Is applicant the sole legal or equitable o.vner? I If No.what is his:her exact share of interest? If owned with someone other than spouse,
indicate with whom:
Yes ❑ No
If name on record is different than that of applicant,indicate below-
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) Is the pr erty in question
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)' Is applicant dsabled and unable to engage in any substantial gainful activity
as defined in IC 6-1 1-12-11(d)?
❑ No [2-1es ❑ No
s the property used and occupied primarily for his/her residences AI Does the applicant's taxable gross income for the preceding calendar year
exceed S17,000?
FA es No • ❑ Yes 2 No
Taxing district Key number I Legal esc tion Record number(contract) Page number(contract)
k • 9 •(If\ G-)8- y- DoD _ ()co. 94o-ow.
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Sign7ature of applicant Address of applicant (number and street city state.and ZIP code)
105 E/ beer 9- di. . � a� -I� 1.061E
' dediti,e4/cr,e,,,h,./1/ A.,
attire oT authorized representative ° I Address of authorized representative nu ber and street,city state.and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day year)
I
Name of contract seller FILED
Taxing district APR 05 2024
k • \.3\ Nr.Ch ArAtiC &.J1i'LA nd)
Key number/legal description GIBSON COUNTY AUDITOR
aG-I% -ay- 0 -crio. 710-o &
Signature of County Auditor Date signed(month,day,year)
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0000566 00031547 3 MB 0.531 0613M3MCS6P1 T217 P17
KIMBERLY A HALL
Ole;t. 105 E MULBERRY ST
FORT BRANCH, IN 47648-1517
The Date You Became Disabled
We found that you became disabled under our rules on August 13, 2020.
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